STRATEGIES FOR
HEALTH PLANS
IN A SHIFTING MARKET
Contributors:
Richard Lachiver,
MD, MPHMedical Director, Provider Integration; Solutions
Maureen TresselLewis
,Director, Provider Integration; Solutions
SUPPORTING THE PATIENT-CENTERED MEDICAL HOME
The conversation is moving for health plans—beyond the longstanding challenge of reigningin healthcare costs to the impacts of healthreform.
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To quality measures with new significance.
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To changing customer expectations.
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To new competitive markets.
Healthways has a 30-year history meeting theneeds of health plan customers. We partnerwith many industry innovators. Our experts atthe forefront of health plan innovation see highpotential for strong advantage in a few game-changing strategies.
GAME CHANGERS
Strategies for Health Plansin a Shifting MarketWe invite you to considerour perspective.
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OPPORTUNITY
Many health plans have historically pursued providernetwork strategy and healthcare services strategy ina relatively independent way. More recently, plans areforging connections between these two areas. ThePatient-Centered Medical Home (PCMH) is part of thistrend. The seven “Joint Principles of the PCMH” definethe model’s core components:
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They include:Personal physician –providing first contact,continuous, and comprehensive care for each patientas part of an ongoing physician/patient relationshipPhysician directed medical practice –a team of individuals (sometimes known as the care team),led by the personal physician, who collectively takeresponsibility for ongoing patient careWhole person orientation –providing for all thepatient’s healthcare needs or appropriately arrangingcare with other qualified professionalsCoordinated and/or integrated care –across thehealthcare system and patient’s communityQuality and safety –hallmarks of the medical homeEnhanced access to care –expanded hours, newcommunication options, open scheduling, and otherapproachesPayment –appropriately recognizing the added valueto patients of a PCMHOther analyses of program cost savings found a$1.50 return for every $1 invested (Group Health), a7% savings in total medical costs (Geisinger), and anestimated statewide program savings in one year of more than $150 million (North Carolina).
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A Healthways review of 16 medical home marketdemonstrations noted a variety of other positiveimpacts:
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Improved HEDIS scores, including diabetes andcoronary artery disease care quality
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Increased well visits, depression screening, andvaccination rates
SUPPORTING THE PATIENT-CENTERED MEDICAL HOME
OVERVIEW
The Patient-Centered Medical Home (PCMH) is an evolving concept that aims to improve cost and efficiencythrough an integrated and holistic approach to patient care. While payment reform is usually inherent inPCMH, many health plans have come to realize that they need more than a reimbursement strategy totruly transform and improve. Health plans that provide substantive support to engage physicians andtransform practices to the PCMH have the potential to achieve cost savings, improve quality, increasemember and provider satisfaction, and elevate population-wide engagement in health and well-beingimprovement through the patient/physician relationship. Working with customers on medical homeinitiatives and reviewing marketplace successes, Healthways has identified five guidelines for highlyeffective health plan support of the PCMH.
A recently published analysis of seven of thenation’s largest and most successful medicalhome demonstrations showed annualreductions in patient hospitalization rangingfrom 6 to 40%. Most programs reportedreductions in ER visits, from 7 to 29%.
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